Palliative Care Essentials for Medical Students
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An overview of the role palliative care plays in the care of the cancer patient.
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Palliative Care Essentials for Medical Students
- 1. Palliative Care: What every 1st year medical student needs to know Suzana Makowski, MD MMM FACP FAAHPM Assistant Professor of Medicine Slide presentation for 1st year medical students in the Cancer Concepts Course at UMass Medical School
- 2. Overview • What is Palliative Care? • What is Hospice? • How do we care for the dying?
- 3. Palliative Care “an approach that improves the quality of life of patients and their families facing the problems associated with life- threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” WHO definition
- 4. Why discuss palliative care? • “It’s not about killing Granny; it’s about keeping Granny alive as long as possible — with the best quality of life.” - Diane Meier, NYTimes
- 5. NEJM Study (2010): Early Palliative Care improves longevity and quality of life for patients with advanced non-small cell lung cancer http://www.youtube.com/watch?v=XHtHXGhTIC4
- 6. What is palliative care?
- 7. Not just end-of-life care…
- 8. Adapted from Frank Ferris – EPEC-O
- 9. Myth: Palliative care = just end-of-life care We often help patients whose life expectancy is good
- 11. Cancer pain prevalence • 50 to 90 percent of oncology inpatients report breakthrough pain • 35 percent of community based oncology practices patients report breakthrough pain • 1 in 3 patients with active cancer report pain • 3 out of 4 of patients with advanced cancer report pain
- 12. Causes of cancer pain • Bone metastases • Visceral metastases • Immobility • Neuropathic pain • Soft tissue • Constipation • Esophagitis • Lymphedema • Muscle cramps • Chronic postoperative scar • Adapted from Twycross R, Harcourt J, Bergl S: A survey of pain in patients with advanced cancer. J Pain Symptom Manage 1996;12:273-282.
- 13. Effects of under treated pain Physical Emotional Existential • Increased catabolic demands: poor wound healing, weakness, muscle breakdown • Decreased limb movement: increased risk of DVT/PE • Respiratory effects: shallow breathing, tachypnea, cough suppression increasing risk of pneumonia and atelectasis • Sodium and water retention Decreased gastrointestinal mobility • Tachycardia and elevated blood pressure • Decreased functional status • Increased chronic pain Depression Anxiety Decreased intimacy Suicidality Suffering – “why me?”
- 14. Pain Assessment • Intensity • Location • Quality • Timeline • Alleviating factors • Meds tried
- 15. Pain Quality Category Cause Symptom Examples Physiologic Brief exposure to a noxious stimulus Rapid yet brief pain perception Touching a pin or hot object Nociceptive/infla mmatory Somatic or visceral tissue injury with mediators having an impact on intact nervous tissue Moderate to severe pain, described as crushing or stabbing Surgical pain, traumatic pain, sickle cell crisis Neuropathic Damage or dysfunction of peripheral nerves or CNS Severe lancinating, burning or electrical shock like pain Neuropathy, CRPS. Postherpetic Neuralgia Mixed Combined somatic and nervous tissue injury Combinations of symptoms; soft tissue plus radicular pain Low back pain, back surgery pain
- 16. WHOpainreliefladder Non-opioid = acetaminophen, NSAID, neuroleptic • Adjuvant = steroid, etc.
- 17. Why is this dangerous? • Mrs. Dolores de Barriga is a 67 year old Peruvian immigrant with metastatic colon cancer, who has increasing abdominal pain. She has a colostomy and has regular bowel movements. • Her current pain regimen is: • Morphine ER 15mg twice daily • Percocet (oxycodone 5mg + acetaminophen 500mg) – 1-2 tablets every 4 hours as needed. She has been taking 2 tablets every 4 hours for the last week.
- 19. Opioid Pharmacology Short-acting Long-acting • Hydrocodone/APAP • Oxycodone +/- APAP • Morphine • Hydromorphone • Oral transmucosal fentanyl • Transdermal fentanyl • methadone • morphine ER • oxycodone ER • Cmax ~ 45 min • T1/2 ~ 2-4 hours • Except fentanyl Cmax and T1/2 vary based on formulation and drug
- 20. A quick quiz What is the half life (range) for opioids? • 2-4 hours How many half lives to get to steady state? • 4-5 What do you base your scheduled dosing on: Cmax or C? • t1/2 What do you base your breakthrough dosing on: Cmax or t1/2? • Cmax
- 21. Opioid pharmacology (except methadone) • Follow first order kinetics • Conjugated by liver • 90-95% excreted in urine • Dehydration, renal failure, severe hepatic failure • Decrease interval/dosing size • If oliguria/anuria • STOP routine dosing (basal rate) of morphine • Use ONLY PRN Why is morphine contraindicated in renal failure?
- 22. Morphine metabolites build-up disproportionately in renal failure • Morphine 3-glucoronide • Not an opioid agonist • Stimulates the GABA/glycinergic system • Can cause neuro-excitation – agitation, hyperalgesia, myoclonus, seizures. • Morphine 6-glucoronide • Active metabolite that acts as an opioid agonist – especially against the mu-opioid receptor
- 23. Palliative Care • Same “rules” apply • CMO ≠ Continuous Morphine Only Optimal symptom management • Goals of care based • Not problem based Personalized healthcare • Bio-psycho-social-spiritual approach • Interdisciplinary Whole-person care
- 24. Myth: Palliative care = “no more treatment” We assess the values & goals of a patient, designing care around them
- 26. Massachusetts facts On an average day in Massachusetts: 144 people die A few childre n 1 infant Some middle aged Most over 75
- 27. MA: 67%want to die at home
- 28. MA: only 24% die at home
- 29. Hospice care: 1 way to help stay home • In the United States, hospice is a form of care provided to patients whose life expectancy is 6 months or less. • It is generally provided in the patient’s home, but can be received in nursing homes, hospices houses, etc. • It is a Medicare benefit (that many other insurances cover) • Its approach is to help people live as well as possible, for the time they have left: alleviating symptoms, reaching goals, supporting family, addressing spiritual needs. • As long as a person’s prognosis remains 6 months, the benefit does not run out. • A patient may be “full code”, “DNR/DNI” – according to their goals and preferences on hospice.
- 30. Hospice Home Palliative (VN) Requires Prognosis <6months (Not required: code status, primary caregiver) Home-bound only Must show improvement Services Nurse, social worker, chaplain, volunteer, home health aide Nurse, PT/OT DME* All covered Not covered Meds Covered if associated with dx Not covered Hours 24/7 Regular business hours Other Bereavement for family up to 13 months after death None *DME = durable medical equipment (bed, oxygen, commode, etc.)
- 31. from Second City
- 32. Much of our practice is for patients nearing end-of-life
- 33. Caring for the dying
- 34. What we know • Until recently, only 10% of medical students had any courses on how to care for dying patients. • Practicing non-abandonment is tough when we don’t know what to do. • Know the signs and symptoms of dying and means to treat them. • Address fears, anticipate problems • Sir William Osler: To cure sometimes, to alleviate often, to comfort always. “ “
- 35. Physiology of dying with cancer • Cancer Cachexia/Anorexia • Metabolic demands of cancer outpace that of the body • Malnutrition: protein and fat depletion • Loss of intravascular oncotic (osmotic) pressure due to low albumin and other proteins • “third spacing” of fluid to abdomen, lungs, subcutaneous tissue How does this differ from starvation?
- 36. Physiology of dying • Decreased perfusion of brain • Increased fatigue, somnolence • Poor control of bowel and bladder • Change in respiratory pattern (late) • Decreased reflexes, including gag and swallow – leads to pooling of saliva in back of throat • Decreased cardiac output • Poor peripheral perfusion: skin breakdown • Decreased perfusion of the kidneys (low intravascular volume/pressure, low cardiac output) leads to pre-renal azotemia Signs/Symptoms • Decreased energy • Increased sleep • Respiratory pattern changes • “Terminal secretions” • Skin breakdown • Peripheral “mottling”
- 37. Pain • Breathlessness • Bleeding Retching • Hallucinations • Seizures
- 38. What signs/symptoms might she experience? • Dolores returns • she is now pancytopenic due to bone marrow involvement • plts now 5,000/mcl, • Hct 12%, • WBC 2,000/mcl Pan = all Cyto = cell (usually referring to blood cells) Penia = poverty
- 39. Where could she bleed? • Brain • Seizures, brain stem herniation • Mucosa • Nose bleeds, vaginal bleeds • Lungs • Dyspnea, hemoptysis • GI tract • Hematemesis, aspiration of blood, bloody stool • Retroperitoneal • Back pain What to do once you can no longer transfuse blood? – Be prepared • For bleeds you can see: dark blue towels, surgicel or topical thrombin for nose/mucosa • Benzodiazepam for seizures • Opioid and benzo of phenobarbitol for hemoptysis, pain, etc.
- 40. Some help:
- 41. • Sir William Osler: • Eric Cassell: “ “ “ “
- 42. Summary • Most physicians practice Palliative Care every day • Palliative care includes any care that enhances quality of life (QOL) – regardless of its effect on longevity (it may prolong life!) • Prognostication is hard, but important. It helps patients plan, achieve goals that they can reach. • Palliative care can help patients at any stage of a serious illness, while hospice is available for patients whose prognosis is on average 6 months.
- 43. How to learn more • EPEC (Education on Palliative & End-of-Life Care) • Lois Green Learning Community www.loisgreenlearningcommunity.org • Get Palliative: www.getpalliativecare.org • Pallimed Connect
Editor's Notes
- My story: This is April. I met her in my clinic in Billings. She first came to me for symptom management of her metastatic breast cancer. She also wanted to know what to eat, how to keep her function high. She was curious about our “Hope for Tomorrow” program for cancer patients. She and her husband joined – and participated in yoga, cooking class, groups support with mindfulness. This picture was taken 6 weeks before she died. 1- my patients found me. They wanted someone to listen, to manage their symptoms while someone else battled their illness, someone to help make plan “b” and to address their whole person. 2- I realized I was not as good at managing symptoms for patients as I thought I was. I thought Zofran was the be-all-and-end-all for nausea. I was wrong. I thought opioids were taught in residency. I was wrong. I thought at end of life, all meds, except morphine and ativan were given, generally speaking. I thought I knew how to tell who was dying. 3- I liked tending to the seriously ill. I was intrigued and curious about their ability to live so very fully. To find joy. To talk about difficult things and to find meaning. I often found them to be more alive than many. They showed me what hope really meant.
- Everybody dies. Cancer continues to be one of the leading causes of death. Good symptom management, coordination of care and help patients live better and longer. The obligation of the physician is to alleviate suffering.
- I used to think that this was the model. We “treat” and then we help people die peacefully. I was wrong.
- It is more like this… but I still don’t fully agree with this picture. After all – it is usually symptoms (except when there are screens) that bring our patients to us: dyspnea, nausea, pain… But anyway, curative and palliative therapies tend to work hand in hand. You do this every day, and better than most.
- The paradigm of palliative care is to approach the person from a multi-dimensional model. Biopsychosocialspiritual was the way I learned it in medical school. Mind-body-spirit might be the way integrative medicine physicians call it. Good care, is another name. Most of us tend to 1-6 with our patients all the time. Even in palliative care, 7 and 8 are often not in the mix.
- Nurse with metastatic breast ca – loves to golf and to work 12 hour shifts. Hip pain was limiting her activity, however. How to respond? Intrathecal pump – coordinated between neurosurgery, anesthesia, and palliative care
- LL is a 57 yo woman with metastatic pancreatic cancer, diagnosed 5 years ago. She now presents to hospital with: Pain (rectal) Breathlessness (pleural effusion and pericardial effusion) Anorexia, weight loss Fatigue Her goals have always been to live as long as possible, to see her children grow, and in the words of USC, to “fight on!” Pain: Opioids, steroids, plus: nerve block – impar or sub-gastric ganglion. Dyspnea: Opioids, chlorpromazine, plus: thoracentesis, pericardial window
- We want to offer hope… so how can we? Story: 21 year old, dying of adenocarcinoma – Crohn’s – bowel obstruction After he was told that the cancer was found everywhere, there there was no more curative treatment available… He asked: Will I have to stay in the hospital or can I get home to see my dog? – He had a 4 month old golden retriever. He didn’t want to see her in hospital – just at home. He is at home now. His brother brought him his golden retriever home. She now visits daily – when he is up for it. He asked his hospice nurse: Will I see my best friend before I die? Where is she? In Germany. Well, we shall see then. They found an agency to help. She flew home 3 days later to spend time with him. I asked him if he had any questions… He asked: When will the bad pain start again? – I answered, If I do my job well, if the hospice nurses do theirs well, it will never start again.
- Everybody dies. Cancer continues to be one of the leading causes of death. Good symptom management, coordination of care and help patients live better and longer. The obligation of the physician is to alleviate suffering.
- You can help them secure their hopes… for how they wish to be cared for at the end of life…
- And avoid what most of us will end up facing
- Everybody dies. Cancer continues to be one of the leading causes of death. Good symptom management, coordination of care and help patients live better and longer. The obligation of the physician is to alleviate suffering.
- Everybody dies. Cancer continues to be one of the leading causes of death. Good symptom management, coordination of care and help patients live better and longer. The obligation of the physician is to alleviate suffering.
- Help our way… Engage with grace – the one slide project – promoted over Thanksgiving National healthcare decisions day – In April – this year, this weekend. Perhaps we could coordinate something for next year?
- Everybody dies. Cancer continues to be one of the leading causes of death. Good symptom management, coordination of care and help patients live better and longer. The obligation of the physician is to alleviate suffering.